Expert advises on best-practice use of antipsychotics

Giving an antipsychotic medication to an aged care resident should only be considered when all other interventions have failed, writes Natalie Soulsby.

In the lead up to, at and since the Royal Commission’s first hearing, there has been much talk about the need to investigate the use of chemical restraint and antipsychotic medications in aged care facilities.

Natalie Soulsby

Chemical restraint is defined as the use of any type of medication to restrict an individual’s movement or freedom. Chemical restraint may be used to manage agitation or aggression or sedating an individual.

The usual medications associated with this are antipsychotics and benzodiazepines.

In some instances, these medications have a specific diagnosis associated with their use, for example schizophrenia, and it is important that the reason for use is documented in the residents drug chart.

Also, all prescriptions in the “when-required” or PRN part of the drug chart should have the reason for use recorded on the medication chart to avoid inappropriate use of these medications. It is important to ensure there is written permission from the resident, or their family, to use these medications.

All aged care homes have a policy in how to deal with residents exhibiting behavioural and psychological symptoms of dementia (BPSD).

The last step in treating someone with BPSD should be medications and it is important to document all the steps that have been taken prior to the need to administer these medications.

Ensuring that there is extra vigilance with the use of those medications prescribed for “when required” use is vital, and if these medications are being used more than three times per month then advice should be sought on the need to review and establish a diagnosis for use of these medications.

The steps taken before pharmacological intervention should include:

a risk assessment to identity any immediate risks to the person with dementia or others within the care environment

a comprehensive assessment that is person centred and considers the following key aspects:

referrer’s description of behaviour

the behaviour

the person

the carer

the care environment

any reversible causes of the behaviour(s) excluded or treated, such as pain, constipation and toileting needs.

Dementia Training Australia offers a range of relevant learning modules to support those working in aged care (click here).

Use and side effects

Giving a medication should only be considered if all else fails.

Only risperidone has Therapeutic Goods Administration (TGA) approval for use in BPSD – and only for those people with a diagnosis of moderate to severe dementia of the Alzheimer’s type – for up to 12 weeks where non-drug measures have been unsuccessful.

It is recommended to start with a low dose and increase as necessary. The recommended dose is 0.25mg twice a day initially to a maximum of 2mg per day.

The 12-week approval limit is due to an increased risk of cerebrovascular adverse effects being identified in this population. This includes things like a stroke, especially in those people with vascular or mixed dementia. All of the atypical (newer) antipsychotics are known to be associated with this risk.

There are other risks associated with the use of this group of medicines in treating BPSD and these include:

confusion

sedation

risk of falls

cognitive decline.

In regards to aggressive behaviours, 9 per cent to 20 per cent of people will benefit. But there is no effect for some behaviours, such as wandering and calling out.

There are many risks associated with the use of antipsychotics including the increase in having a stroke or a mini stroke which is why the TGA changed their approval to a maximum of 12 weeks treatment and then to review.

It is estimated 18 out of 1,000 people treated with an antipsychotic for 12 weeks will experience a stroke or mini stroke. Other risks include a two fold increase in the risk of pneumonia, problems with gait, such as unsteadiness, and confusion or sedation.

Before antipsychotics are prescribed the clinician will weigh up the risk versus the benefit of the medication.

Remember that medications should only be given if all other non-medication related options have been trialled and this has been documented in the residents’ notes.

If it’s not documented, then it didn’t happen.

Permission from the family must be given prior to administration of antipsychotics to treat BPSD and they must be used at the lowest dose for the shortest time necessary.

Natalie Soulsby is a clinical pharmacist, specialist in geriatric medicine and Head of Clinical Development at Ward Medication Management. She won the AACP 2017 Consultant Pharmacist of the Year and the 2016 South Australian Pharmacist of the Year awards.

One Response to Expert advises on best-practice use of antipsychotics

Until we lose the “BPSD” paradigm we will always fall back on the use of restraint to try and resolve issues that very often are not “caused” by the dementia. To say only use when all else has failed is still not good enough given we know how ineffective and dangerous these drugs are for people living with dementia. I also question the 9% to 20% of effectiveness, how sedated did the person have to become for the behaviour to be affected? Is that really a success?
Labelling peoples expressions of ill-being, or in some cases very understandable behaviour, as “wandering” or “shouting” fails to see why the person is doing this. We know chronic pain is still massively unrecognised and untreated in people living with dementia. is the person walking around because it is too painful to sit in one place? Is that “wandering” or a very normal human response to being in pain? It’s time to lose the catch all BPSD language and genuinely move to person centred care where we explore each individuals needs and work differently to meet them. Only then will we stop sedating, dangerously, our most vulnerable elders.